Reasons why claims and invoices are not produced

This article serves as a checklist of reasons why a claim or invoice was not created in the system and where you may go to resolve.

► Demographics

Client does not have a DOB entered. Reports > Clients > General > Client Roster using flag Client Missing DOB.

Client age does not match age range on the contract rate. (N/A)

Client had a date of birth in the period or prior where he is no longer billable under the age rate set on the rate (Clients age must be < the upper age range entered on the rate setup). (N/A)

► Clients Benefit Assignment

Does not have one entered. Reports > Clients > General > Client Roster using flag No Benefits Assigned.

Effective dates are not within the period of the service or placement being billed.
Reports > Clients > General > Benefits Assignments

Benefit assignment was deleted (strike thru on it or view only when you attempt to open it). (N/A)

Another contract is in a higher billing sequence than the one you expect to be billed to so the service/placement is actually going to be or have been billed to that sequence instead (check if billed by running billing report from clients placement/service you expected to be billed).
Reports > Clients > General > Benefits Assignments

► Authorizations

Authorization doesn’t exist (N/A) If contract is not flagged to hold if no auth entered, system will NOT create a bill.

Authorization details not entered (N/A) If contract is not flagged to hold if no auth entered, system will NOT create a bill.

The contract service selected on the authorization is not the same as the one provided. To be sure not same spelling and actually different service – select again the correct one, see if it turned red. Client Services Report vs. Authorizations report.

Units on the entered authorization (on the header or service) are or will be exceeded by what you are billing. Client Services Report vs. Authorizations report.

The expected bills service is not within the effective dates of the authorization – both header and details. Client Services Report vs. Authorizations report.

► Clients Enrollment Information

Contract is set up to use a program modifier and doesn’t have provision for “all”, client has a program modifier different than the ones setup or doesn’t have one at all. Reports >Clients >General >Critical Information… Filter by program if necessary. Download Data and use excel filter to show only where PD is NULL.

Contract is set up to bill per Managing Office and doesn’t have provision for “all” managing offices, client is enrolled in a facility tied to managing office not designated on the contract.

Effective date of enrollment is after the “Bill Through” of the billing run. Client Roster

Client’s Program enrollment does not match what is defined on the contract Client Roster and/or Status Changes report. *Note: Using the Report Selection “Order by Supervisor/Primary Worker/ Client Name will report ALL Active clients within the reporting period if active at least 1 day within the period even if no changes were made.

Client had a placement disruption for the period which is not billable under the placement disruption rules associated in the contract. Client Roster and/or Status Changes report. *Note: Using the Report Selection “Order by Supervisor/Primary Worker/ Client Name will report ALL Active clients within the reporting period if active at least 1 day within the period even if no changes were made.

Client has an open placement disruption (no end date). System will not create a claim for service days for an open disruption. Reports >Clients >General >Placement Disruptions

Client was transferred after the bills for original placements were created, new placement will not bill for overlapping period. Status Changes report. *Note: Using the Report Selection “Order by Supervisor/Primary Worker/ Client Name will report ALL Active clients within the reporting period if active at least 1 day within the period even if no changes were made.

Client’s Program Enrollment does not have a primary worker (allowed on intake if agency permits). Reports >Clients >General >Client Roster *Download data and filter by Primary Worker column where entered as “Worker Not Assigned”.

► Service Entered Information

Program providing the service does not match what is on the contract. Reports >Clients >Services & Treatment >Client Services vs. Billing Contract Setup area

Date of services is after the “Bill Through” of the billing run. Reports >Clients >Services & Treatment >Client Services adjusting date rates as needed, or open client and review the Service Entry area.

Date of services is before the “Bill From” Date entered on the billing run. Reports >Clients >Services & Treatment >Client Services adjusting date rates as needed, or open client and review the Service Entry area.

Service is marked “do not bill” (may appear as "Exempt From Billing" on the Service form). Flag in include or not include Do No Bill on Client Services and Service Entries Reports.

Date of service is not within the range of the clients benefit assignment. Benefits Assignments vs. Services Reports

Event is marked as multi-day event but the user does not have the ability to enter the end date on the form. Services not billed reporting and review of event setup settings (no report for this)

Duration is not entered and the rate uses a time chart where time DOES matter in calculating units. Services Reports and Billing Rate Setup Report.

Duration does not meet the requirement for billing as defined on the rate history setup. Services Reports and Billing Rate Setup Report. (*Note: Min/Max Consolidated Time Fields do not appear on billing rate setup report, only the min/max time on rate details)

Service is marked as no-show and there is the associated rate on the contract for the service does not have a no-show rate.

Client can bill for placement/attendance days, but Qualifying Services have not been entered or not enough were entered based on rate rules. Client Services Reports, Client Service Entry Screen

Service has been flagged as 'Do Not Bill/Exempt from Billing'. This can be un-checked using the Billable Client Services Report (Reports>Clients>Services & Treatment>Billable Client Services)

Service has been flagged 'Off-Site' and there is no associated rate on the contract that is flagged 'Off-Site'.

Service has been flagged 'Language Other than English' and there is no associated rate on the contract that is flagged 'Language Other than English'

► Contract Setup

Contract does not have an associated rate for the billed service.

Program and service/placement that you expect to be billed from the client does not have a rate associated to it and/or is not defined on the contract.

Contract requires service authorization for the program service/placement and the client does not have a valid one on file.

The services/placement date range you are trying to bill is < the dates entered on the agency information screen identifying when to start billing in myEvolv.

Contract line in setups has “Prevent Untimely Filing” checked and the service date is after the Number of Days for Timely Entry entered.

Contract line was made inactive.

Services delivered are above the Capitation limit defined on the Payer/Contract Setup.

*No Reports available for checking. Must go into the setups and review.

► Rate Setups - General

Rate Header... Finance Setup >Billing Rates (A/R) >**RATE CATEGORY (Manual, Placement, etc) > Rates Setup

Rate is flagged as an E/M rate, but the service entered does not have E/M information

Rate is NOT flagged as Allow Billing EM services but the service has EM information entered.

Rate History... Finance Setup >Billing Rates (A/R) >**RATE CATEGORY (Manual, Placement, etc) > History or History (Simple)

Effective date of the associated rate is not within the time you expect to bill (Not effective)

Rate is setup as a 0.00 rate (typical for variable billing based on client) and there is no authorization present if flagged on the contract. System will not create a 0.00 original claim.

Rate Method on Rate History record is empty.

Associated Plans sub form does not contain the Contract you are trying to bill.

► Service Based Rates

Service is flagged with one of the following variables but you do not have a rate detail line checked to allow to bill for... No Show, Language Other Than English, Off Site, Interactive Complexity, 

Duration on the service is entered as 0, however rate setup uses a time chart that counts units based on time.

Staff credentials or staff member is a variable in determining the rate which the staff who provided the services does not have this credential on their staff information. Review Staff Credential Setup in Staff Profiles with Security.

Has Activity type and/or Encounter with as a variable in determining the rate but this was not entered on the service provided. Client Services reports data download only vs. Billing Rate Setup Report.

Min and max time is entered as a variable on the rate setup in either rate details (looks at each service) or rate rules (looks at total time of all consolidated services) and client’s service(s) is not within that time period. Services Reports and Billing Rate Setup Report.

Rate is specified per Facility. Client may not be enrolled in the billable facility. No Report Available, need to look at Rate History.

Min/Max Consolidated Time as a variable and the total time for the consolidated may be more or less than what’s entered on the rate. Services Reports and Billing Rate Setup Report. (*Note: Min/Max Consolidated Time Fields do not appear on billing rate setup report, only the min/max time on rate details)

► Placement/Attendance Based Rates

Rate is marked as applying to a full period and something less than 100% is entered in the “%services to qualify for period” field and client was placed less than this % and none of the period would be billed is selected in the “If not full period, apply Rule” field. Need to check Rate Setups directly.

Rate uses Min/Max Units (days) and the enrollment time does not match. Need to check Rate Setups directly.

Rate setup may be for a specific disruption. A disruption other than what’s on the rate setup may be on the client record. Need to check Rate Setups directly.

Min and max time is entered as a variable on the rate setup (Rare) and client’s placement is not within that time period. Need to check Rate Setups directly.

The Rate Method is Placement Based but should be Attendance Based, or vice versa. Need to check Rate Setups directly.

Rate is specified per Facility. Client may not be enrolled in the billable facility. Need to check Rate Setups directly.

Rate uses qualifying services. Need to check Rate Setups directly. Services may…

• Not be enough to bill
• Not be entered
• May not be enough ‘Client Involved’
• May not be enough in a ‘Family Caregiver Setting’

► Miscellaneous

Client Data was changed after the Billing Run was created. Once completing all of the above steps and where you feel it still should have been billed, reprocess again to see if billed. NA

You are billing an Outpatient Program for care days but you do not have the program setup to Create Services for Days of Placement. Program Setup area > Outpatient Programs

Why would claim not appear on care days report even though bill is produced?

• Program facility placement billed is not setup/checked in Finance Setup > Payers/Contracts Setup> Payers > Care Day Reporting Setup.
• The Services cut-off date in the Agency Information form is empty; if so, the system uses the install date as the service cut-off date.